TR-305, 03/12 Petition for Half-Priced Ignition Interlock Device (IID) 247343.301, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 2 STATE OF WISCONSIN, CIRCUIT COURT, COUNTY State of Wisconsin , Plaintiff, - v s - Defendant Address City, State, Zip Amended Pe tition for Half - Priced Ignition Interlock Device (IID) Case No. UNDER OATH, I STATE: I am unable to pay the full price of Ignition Interlock because of poverty and am requesting that I have limited liability of one-half of the cost of equipping each motor vehicle with an ignition interlock device and one-half of the cost per day per vehicle maintaining the ignition interlock device. 1. I am am not married. 2. I am am not employed. Name of employer: 3. I earn (gross pay) $ weekly. every 2 weeks. twice monthly. monthly. My take-home pay (after taxes and deductions) is $ per pay period. 4. I receive gross monthly income totaling the amount of $ from Pension Social security Unemployment compensation Disability Student loans/grants Other: 5. I have the following cash assets: Savings accounts: $ Cash: $ Checking accounts: $ Money owed me: $ 6. I have the following other assets: Vehicle-Yr./Make: $ Household furnishings: $ Vehicle-Yr./Make: $ Equity in real estate: $ Other individual assets valued over $200 each: $ 7. My household consists of myself and others: Full name: Relationship to me: Under age 18 Yes No Full name: Relationship to me: Under age 18 Yes No Full name: Relationship to me: Under age 18 Yes No Full name: Relationship to me: Under age 18 Yes No Full name: Relationship to me: Under age 18 Yes No 8. The other members of my household have gross monthly income totaling the amount of $ from Wages Social security Relief funded under public assistance Food stamps/FoodShare Pension Student loans/grants Unemployment compensation Supplemental security income Disability Relief funded under 24759.53(21), Wisconsin Statutes Support/maintenance Other: 9. I have the following debts: Amount Monthly Payment a. Mortgage/Rent $ b. Auto loan $ c. Credit cards $ d. Other: $ $ American LegalNet, Inc. www.FormsWorkFlow.com TR-305, 03/12 Petition for Half-Priced Ignition Interlock Device (IID) 247343.301, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 2 10. I have the following unusual expenses, other than ordinary living expenses: State of County of Subscribed and sworn to before me on Notary Public/Court Official Name Printed or Typed My commission/term exp ires: I understand that if my financial situation changes, I must notify the court immediately. Signature Print or Type Name Date of Birth Address Date DISTRIBUTION: 1. Court 2. Defendant American LegalNet, Inc. www.FormsWorkFlow.com